5 Questions: Sam Gambhir on progress in precision health

A perspective piece from Stanford scientists provides an overview of the value of precision health, its progress, challenges and how it can improve health at the individual and population level.

Feb 282018

Sam Gambhir

Patient care has long hinged on doctors treating patients once disease has already set in, but the emerging focus on precision health aims to change that dynamic. The idea is this: Empower individuals to monitor their own health, and use the collective data to piece together a high-resolution picture of human health at the population level. The goal is not just to glimpse the finer details of health and disease, but to consistently track and actively apply the findings to prevent disease or detect it earlier.

Stanford Medicine, led by Dean Lloyd Minor, MD, began laying the groundwork for precision health in 2015 in an effort to provide targeted, predictive and personalized care. Stanford researchers were also working with the Canary Foundation as early as 2008 to lay out a roadmap of precision health, specifically for early cancer detection.

In a perspective piece published Feb. 28 in Science Translational Medicine, researchers at the School of Medicine examine some of the key building blocks of precision health, give examples of cases in which it’s already happening and highlight the role that monitoring technologies will play in elevating its success as a whole.

Q: How does the practice of precision health change standard doctor-patient relationships?

Gambhir: Precision health creates an opportunity for the entire health care team, including physicians, to utilize more detailed and comprehensive health data sets to be better-informed about their patient's individualized health. In turn, it allows physicians to more accurately address their patient’s health risk profile and tailor monitoring methods and early intervention to that individual. This type of approach will empower doctors to be more focused and directed in how they treat patients.

For patients, increased health monitoring allows them to more proactively engage in their own health — in some cases in real time — and see how it relates to their lifestyle or other health factors. Rather than simply follow a standard appointment schedule, patients would only visit their physician when needed, but they could still have contact with their health care team through a secure health portal. This approach could, when appropriate, reduce the number of patients visiting the clinic and allow physicians to more thoroughly engage with the patients who do come.

Q: Explain the concept of “pre-patient care” and how it fits into precision health.

Gambhir: Not all health conditions require a regular visit to the doctor. An integrated health portal analyzing data from “smart” devices in the home and on the body could monitor a range of health data — from sleep patterns to biomarkers — and notify your physician if something seems out of the norm. Because health data would be “normalized” to each person, rather than only using trends from the population, individual abnormalities could be detected more frequently. Each individual becomes their own “control.”

The physician and health care team could then use the information from the integrated health portal and, with their personal knowledge and experience, create interventions that would promote and improve overall health. Patient monitoring could range from minimal to continuous and could have the potential to empower patients to maintain their health. The goal: keep patients out of the clinic when they don’t need to be there and have them visit their physician only when necessary. An active partnership and trust between patient and physician is a must if we’re to maximize the benefit of these emerging approaches. This open communication and partnership is facilitated through secure health portals, regular remote health surveillance and early interventions when necessary.

Q: What kind of role will technology play in improving the health of individuals as well as large populations?

Gambhir: Wearable technology, including implantables; data analytics; and an understanding of the mechanisms and biomarkers associated with the transition from health to disease state will be necessary in improving health care beyond current standards. Furthermore, passive measurements through “smart home” devices — such as a toilet that monitors biomarkers or a toothbrush that analyzes saliva — and other monitoring technologies that run in the background will be a crucial piece. The bathroom and kitchen could become two of the most important rooms in the home from a health-monitoring perspective.

Everyone, at and even before birth, could have a unique health-risk profile created. Based on this profile, physicians would prescribe appropriate wearables or other health monitoring or surveillance methods. Over time, an individual’s monitoring needs will likely change, and this adaptation process will allow the types and frequency of health measurements to evolve with the patient through age, health status and other factors.

On a population level, shared health data sets could be useful in improving the predictability of health risk models. While not every data point will be relevant for each person, it would allow those at inherent risk for particular health conditions to be identified earlier, when positive clinical outcomes are still possible. Additionally, health-sensor technologies have already been adapted into cellphones and could be deployed into other settings too, like bathrooms, cars or public transportation.

Q: How close are we, technologically speaking, to being able to realistically monitor individual health on a large scale, consistently?

Gambhir: The greatest challenge to understanding human disease is accurately and reliably monitoring the transitions that take place throughout the continuum of disease. Effective disease biomarkers are also essential. The technical capability and accuracy of health monitoring systems already exist for many conditions and could be produced at scale, but these devices are only as useful as the predictability of the biomarkers they measure. It’s important to note that technology is ahead of our understanding of the underlying biology.

We’re already able to monitor human health in a number of ways; however, it’s critically important to identify the most informative and useful data. In addition to Stanford, many companies, such as Apple, Amazon, Google and Verily, are innovating in the human health arena.

Beyond development, validation and scalability, another important challenge is widespread adoption. User engagement will be critical to eventual success of these strategies: Real people and health providers will need to see value in using these devices in order for these health-monitoring approaches to be effective.

Q: What do you and your colleagues see as some key ways to persuade large populations to not only participate in precision health efforts but to be active collaborators?

Gambhir: For precision health efforts to be successful, we as a society will need to work together. These efforts are bigger than any one group can tackle alone, and they require large numbers of participants over very long time horizons. That said, while there’s great potential for individualized monitoring, each individual participant also benefits the overall population. In this way, active participation, whether as a study participant or investigator, can give back to the community by helping everyone stay healthy for as long as possible.

We have created and are involved in multiple large efforts. This includes the new Precision Health and Integrated Diagnostics Center at Stanford, and Project Baseline, which is a collaboration between Duke, Stanford, Google and Verily that launched in mid-2017 and was designed over a three-year period by more than 70 investigators. These efforts encourage investigators and participants from our community and beyond to get involved in precision health practices.

Furthermore, it’s crucial to emphasize to participants that early detection and intervention are the best ways to improve health outcomes. Too often, disease is detected too late for treatments to be effective. This paradigm shift toward precision health seeks to keep society healthy for as long as possible, and catch disease before it strikes.